Prepared by Division of Medical Quality Assurance

REAPPLICATION FOR CANDIDATES REQUESTING

SPECIAL TESTING ACCOMMODATIONS

IN ACCORDANCE WITH THE

AMERICANS WITH DISABILITIES ACT

Reapplication has only one part and must be completed by the candidate.

Instructions:

A. Who Should File the Application: Only previously accommodated candidates seeking special

B.

C.

D.

E.

F.

G.

testing accommodation for an Americans with Disabilities Act (ADA) disability should use this

form. Use form DH-MQA 4000 if you are requesting a special testing accommodation for the

first time. Use form DH-MQA 4001 if requesting an accommodation due to a religious conflict

and use form DH-MQA 1192 if requesting the use of a translation dictionary.

Application Submission Deadline: Completed applications must be submitted at least 60 days

prior to the examination for which you are requesting special testing accommodations. If

submitted with less than 60 days until the examination, the department will provide any such

requested accommodation that can be made available without posing undue burden or

jeopardizing the security and integrity of the examination. If a candidate who requires an

accommodation fails to timely request such, then the candidate must reschedule their

examination date.

Required Documentation: If a complete and approved Part II of the Application for Candidates

Requesting Special Testing Accommodations in Accordance with the ADA is on file and no

changes have occurred in your disability, you do not need to re-file Part II of the application.

Review: A review of each application will be completed after each submission. The department

will defer the review of each application until all necessary documentation is completed and

submitted.

Type or Print All Information on the Application: Do not leave sections blank, insert ¡°N/A¡± if

the section does not apply.

Emailing Information: For faster service submit your reapplication and any supplemental

documentation you are sending with your application to the following email address:

mqa.specialtesting@.

Mailing information: If you cannot email your application, submit your application and any

supplemental documentation you are sending with your application to the following address:

Florida Department of Health

Division of Medical Quality Assurance

ATTENTION: ADA Accommodations

4052 Bald Cypress Way, Bin # C-91

Tallahassee, FL 32399-3250

DH-MQA 1191, Revised 10/2020

1

Note:

¡ñ Send via email or mail. Do not send your application for special testing accommodations by

both email and mail.

¡ñ Do not send your request for special testing accommodations reapplication to the board

office.

¡ñ Do not mail your application for licensure or examination to this address because this will

delay action on your reapplication.

REAPPLICATION FOR CANDIDATES REQUESTING

SPECIAL TESTING ACCOMMODATIONS IN ACCORDANCE

WITH THE AMERICANS WITH DISABILITIES ACT

SECTION 1: PERSONAL DATA

1. Name:______________________________________________________________

First

Middle

Last

Date of Birth: _____________________

_____________

______________

Month

Day

Year

2. Mailing Address: _______________________________________________________

Street

Apt. Number

___________________________________________________________________________

City

State

ZIP Code

Email: _____________________________________________________________________

3. Phone Number: (____) ________________ (Mobile)

(____) ________________ (Work)

SECTION 2: EXAMINATION FOR WHICH ACCOMMODATION IS REQUESTED

1. Profession: _________________________________________________________________

2. Month / Year of Exam: ________________________________________________________

3. Name of the Examination (check all those that pertain and identify by name):

___ (1) Laws and Rules

DH-MQA 1191, Revised 10/2020

2

___ (2) National

___ (a) Practical __________

___ (b) Written __________

___ (c) Specialty(ies) (if applicable): __________

___ (3) State Exam

___ (a) Practical __________

___ (b) Specialty(ies) (if applicable): __________

___ (4) Other (explain): ___________________________

SECTION 3: FORMER SPECIAL TESTING ACCOMMODATION(S)

1. What was the date of the last examination for which Testing Services in Florida provided

special testing accommodations? ________________________________________________

____________________________________________________________________________

2. Have there been any changes in your disability?

____ Yes

___ No

3. If Yes, please explain: __________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

4. What accommodations were provided? (Check all that apply)

____ Extra time

Amount of extra time provided: _______________

____ Separate room

____ Other (please list): ________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

SECTION 4: Certification

I certify that the above information is true and accurate. If the test accommodations granted to me

include a deviation from the standard testing time schedule, I agree that, from the time I begin the

examination until I have completed it, I will not communicate in any way, to the extent possible, with

any other individuals taking the examination and I will not communicate in any way with any such

individuals about the content of the examination.

DH-MQA 1191, Revised 10/2020

3

Signature: ___________________________________

Date: __________________

I understand the Department of Health will use the information obtained by this authorization to

determine eligibility for a reasonable accommodation in regard to this examination by reason of my

disability. This information will remain confidential pursuant to the provisions in Section 456.014,

Florida Statutes. If clarification or further information regarding the documentation provided is

needed, I authorize the Department of Health authority to contact the professional(s) who diagnosed

the disability and/or those entities to communicate with the Department of Health in this regard to

provide the Department with such clarification and/or further information.

Signature: ___________________________________

DH-MQA 1191, Revised 10/2020

Date: __________________

4

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